NURS 190 PHYSICAL ASSESSMENT PA MIDTERM /KIM HEIN
1.
The nurse is performing a comprehensive skin assessment. Which of the following pieces of equipment
is appropriate to use during the skin assessment?
(2 Points)
doppler
Wood's lamp
Reflex hammer
Goniometer
2.
Which of the following is an expected finding in a healthy client on assessment of Stensen's ducts?
(2 Points)
red glow is present
midline and symmetric
saliva is present
redness is present
3.
Which of the following signs or symptoms does the nurse recognize in a client with hypothyroidism?
(Select all that apply)
(2 Points)
Fatigue
intolerance to cold
increased cardiac output
constipation
4.
The client has a new diagnosis of right sided heart failure. The nurse understands a client with right sided
heart failure may have edema and jugular vein distension.
(2 Points)
True
False
,5.
The nurse performs the Romberg test to assess for:
(2 Points)
balance
hearing
vision loss
cranial nerve 6 dysfunction
6.
Which of the following techniques will the nurse perform to assess for signs of breast abnormalities?
(2 Points)
inspection, palpation, and auscultation
inspection and palpation
inspection, palpation, and percussion
palpation and auscultation
7. The nurse is caring for a client with obesity. The nurse places the client in which of the following
positions to best hear heart sounds?
supine
prone
sitting upright
left lateral
8.
State at which location(s) the S1 sound (lub) is heard loudest on cardiac auscultation. State why the S1 is
loudest at these locations. (Write 1-2 sentences).
If you are you are at the proper location, you will hear the sound the loudest.
(2 Points)
9.
The nurse palpates an enlarged lymph node at the back of the ear, over the mastoid bone. The nurse
documents this location as:
(2 Points)
posterior auricular
,submental
posterior occular
occipital
10.
The older adult client is admitted with new onset pain and pressure to their eyes. On inspection, the
sclera is red and the pupil is an irregular shape to the left eye. The nurse should further assess for:
(2 Points)
macular degeneration
cataracts
presbyopia
Glaucoma BOOK REF. PG 253
11.
The client is seen in the urgent care center with a suspected fungal infection to the fingernails. The nails
are thick, yellow, and lifting off the nail bed. The nurse documents this finding as:
(2 Points)
clubbing
Onycholysis BOOK REF PG. 203
beau's lines
splinter hemmorage
12.
The nurse assesses the client's radial pulses and documents these findings: 68 beats per minute, regular,
2+, symmetrical. The physician asks the nurse, "What was the client's pulse amplitude?" The best
response of the nurse:
(2 Points)
"68 beats per minute"
"regular"
"2+" BOOK REF PG 404
"symmetrical"
13.
, The nurse is performing a cardiac auscultation and hears a harsh, blowing sound that is very loud at the
4th ICS, left sternal border. No thrill is present. The nurse understands this murmur is graded as:
(2 Points)
grade 4
grade 2
grade 3
grade 5
14.
Which of the following clients is most at risk for developing a deep-vein thrombosis?
(2 Points)
A 30 year old client with is 1 week post delivery of a baby
A 60 year old client who is on anticoagulant medications
A 45 year old client on oral contraceptives and smokes
A 40 year old female with underwent laser eye surgery
15.
The nurse is performing an otoscope exam on a child in the outpatient clinic. Which of the following
safety measures should the nurse observe when performing this exam?
(2 Points)
Position the dorsal surface of the hand on the child's head
Look in the right eye with the nurse's right eye
Pull the pinna up and back
Look in the right ear while holding the scope in the left hand
16.
Which of the following terms best describes a complete inspiratory phase and expiratory phase of
breathing?
(2 Points)
Cardiac cycle
Eupnea
pneumothorax
1.
The nurse is performing a comprehensive skin assessment. Which of the following pieces of equipment
is appropriate to use during the skin assessment?
(2 Points)
doppler
Wood's lamp
Reflex hammer
Goniometer
2.
Which of the following is an expected finding in a healthy client on assessment of Stensen's ducts?
(2 Points)
red glow is present
midline and symmetric
saliva is present
redness is present
3.
Which of the following signs or symptoms does the nurse recognize in a client with hypothyroidism?
(Select all that apply)
(2 Points)
Fatigue
intolerance to cold
increased cardiac output
constipation
4.
The client has a new diagnosis of right sided heart failure. The nurse understands a client with right sided
heart failure may have edema and jugular vein distension.
(2 Points)
True
False
,5.
The nurse performs the Romberg test to assess for:
(2 Points)
balance
hearing
vision loss
cranial nerve 6 dysfunction
6.
Which of the following techniques will the nurse perform to assess for signs of breast abnormalities?
(2 Points)
inspection, palpation, and auscultation
inspection and palpation
inspection, palpation, and percussion
palpation and auscultation
7. The nurse is caring for a client with obesity. The nurse places the client in which of the following
positions to best hear heart sounds?
supine
prone
sitting upright
left lateral
8.
State at which location(s) the S1 sound (lub) is heard loudest on cardiac auscultation. State why the S1 is
loudest at these locations. (Write 1-2 sentences).
If you are you are at the proper location, you will hear the sound the loudest.
(2 Points)
9.
The nurse palpates an enlarged lymph node at the back of the ear, over the mastoid bone. The nurse
documents this location as:
(2 Points)
posterior auricular
,submental
posterior occular
occipital
10.
The older adult client is admitted with new onset pain and pressure to their eyes. On inspection, the
sclera is red and the pupil is an irregular shape to the left eye. The nurse should further assess for:
(2 Points)
macular degeneration
cataracts
presbyopia
Glaucoma BOOK REF. PG 253
11.
The client is seen in the urgent care center with a suspected fungal infection to the fingernails. The nails
are thick, yellow, and lifting off the nail bed. The nurse documents this finding as:
(2 Points)
clubbing
Onycholysis BOOK REF PG. 203
beau's lines
splinter hemmorage
12.
The nurse assesses the client's radial pulses and documents these findings: 68 beats per minute, regular,
2+, symmetrical. The physician asks the nurse, "What was the client's pulse amplitude?" The best
response of the nurse:
(2 Points)
"68 beats per minute"
"regular"
"2+" BOOK REF PG 404
"symmetrical"
13.
, The nurse is performing a cardiac auscultation and hears a harsh, blowing sound that is very loud at the
4th ICS, left sternal border. No thrill is present. The nurse understands this murmur is graded as:
(2 Points)
grade 4
grade 2
grade 3
grade 5
14.
Which of the following clients is most at risk for developing a deep-vein thrombosis?
(2 Points)
A 30 year old client with is 1 week post delivery of a baby
A 60 year old client who is on anticoagulant medications
A 45 year old client on oral contraceptives and smokes
A 40 year old female with underwent laser eye surgery
15.
The nurse is performing an otoscope exam on a child in the outpatient clinic. Which of the following
safety measures should the nurse observe when performing this exam?
(2 Points)
Position the dorsal surface of the hand on the child's head
Look in the right eye with the nurse's right eye
Pull the pinna up and back
Look in the right ear while holding the scope in the left hand
16.
Which of the following terms best describes a complete inspiratory phase and expiratory phase of
breathing?
(2 Points)
Cardiac cycle
Eupnea
pneumothorax
